#36. “It’s the Love”

“It’s the love,” that is what a good friend and experienced therapist dared to say some years ago. Let me take a break from the series of posts about therapist objectives to discuss recent comments about healing an intense attachment to one’s therapist.

A reader wrote:

I guess my hope is that, as someone who teaches therapists, you will nuance your claims about how childhood needs can’t be fulfilled. I think therapists often use this reasoning against clients in ways that are really damaging. And, perhaps more importantly, this reasoning causes people like me to settle for of continued pain when that is not necessary.

I am writing this post knowing that nuance implies a greater level of ambiguity and subtlety. Please read this post as relatively impressionistic. My aim is to give ideas, not to be definitive. So I hope my readers will not take it too literally or seek rigid rules. Every client is different and every client-therapist relationship is unique. I wish all the best.

Do therapists get attached?

Yes, for the most part. As with human nature in general, it is totally natural and healthy for therapists to care and feel connection with clients when they know enough for empathy to develop. Responding this way is an essential part of our nature as a species whose survival has always depended on social relations. Can it be suppressed? Yes, there are people for whom empathy is blocked or the capacity is missing. Those people should probably not be therapists. So, in general, the answer is that we therapists can’t help getting attached to clients. It’s a kind of love, but also a love that comes with clarity that there are boundaries.

Many therapists have been taught that sharing this information with clients is a bad thing to do. I think this attitude has its roots in the Victorian era. That outlook was still prevalent when Bowlby studied British orphanages of the 1940s and came to the then surprising conclusion that withholding warmth or affection was actually damaging. Also the 40s, the psychoanalytic community was still convinced that the therapist’s emotions should be withheld for the ostensible reason that it might damage the transference and spoil objectivity. I think that was a similar vestige of the Victorian emphasis on control of “base” instincts. In my experience, transference is a robust phenomenon that easily overcomes whatever bit of humanity might peek through the curtain.

Relationship is such a powerful force that it affects therapists in training. Bathed in a professional community where covering up feelings is highly valued, it is not surprising that practitioners should remain anxious about showing their human responses. Besides fitting in with the community a truly valid reason might be that the therapist is uncertain or vulnerable about boundaries, in which case it would be better for that therapist not to take on the client or to obtain serious help. Not every therapist has been so self-aware.

Beyond the latter serious therapist limitations, I don’t see good reasons for voluntarily hiding one’s feelings. Letting the curtain drop may cause anxiety for the therapist. It means letting go of the comfort of privilege and power. And yes, being human is delicate. There are ways to express feelings that can easily be misconstrued. Here is a good description of how to do it from the point of view of the blog reader quoted above:

However, some of my experiences with my current therapist have been really different. Unlike my previous therapists, she actually tries to meet my young parts needs. I’ve been surprised at how flexible and creative she’s been in doing this. And I’ve found that, while imperfect, these attempts have been largely successful.

Some clients are better able to tolerate a degree of distance and an impersonal relationship with their therapist. Perhaps they have less early life damage or perhaps their self-protection is stronger because they have had even more hurt and are simply better at defending themselves. Even if they can tolerate such a therapeutic context, it does not mean that treatment will be more effective or shorter. Because psychotherapy does, and should, go deep into the personality, I think that therapy conducted at an emotional distance will generally be slowed down or limited to the extent that a genuine emotional relationship is denied.

In answer to the reader at the start of this post, It is true that 24/7 primal love is impossible to duplicate in adult life, but it is also true that the very best part of primal love is empathy, being accurately tuned in, which is abundantly possible within the therapeutic context. Overall, then, I have to agree with the reader that showing humanity, while remaining sensitive to how our verbal and nonverbal communications are received, should be seen as the standard for good therapy. Now let’s look at how abuse and deprivation at different stages of development may affect the client’s quest to heal.

The deepest, earliest, level of attachment damage

When clients (I’m still reeling from a scathing comment on my use of “patient”) get very attached to their therapist it is usually because of a shortfall in primal love from long ago. The deepest level of damage is failure to internalize “basic trust,” probably similar to a reliable sense that things will somehow turn out OK or a feeling that one still exists even when the therapist is not physically present, as with object constancy. One reader wrote this:  

This might sound odd, but after every therapy session, it’s as if I’ve died to my therapist. By that I mean, for no logical reason, I think that the only time my therapist ever thinks about me is when I’m in her rooms having a therapy session.

Here she shows just such a failure to internalize a basic sense of being connected. Along with it, we can also expect damage to the ability to trust. Both can be sources of difficulty taking in therapist caring even when it is available. Clients will naturally experience a great deal of mistrust and will withdraw instantly at a sign that the therapist is not completely genuine. Paradoxically, these may also be people who, out of intense need, have trusted, or overridden their mistrust, when they should not have.

This situation obviously poses problems for the therapy. Even a relatively trustworthy therapist may not be trusted or may go through a long period of scrutiny. Often, the things that finally convey trustworthiness are the slips and uncontrolled moments that reveal a therapist’s genuine humanness. Reassurances, while appreciated, are likely to be taken with a degree of doubt or a “wait and see” attitude. Such encouraging words may not lead to enduring change but express the therapist’s good will and can help to sustain the relationship while waiting for trust to emerge.

As trust is established, internalization of a positive relationship seems to happen very gradually, even over years. As I have stated elsewhere, I believe the triggers for each increment of internalization are moments of attachment anxiety, as in saying good-bye and in necessary separations.

Damage from (slightly) later in development

This discussion is informal and not necessarily precise or complete. In my mind, consequences from a bit later in development are different. I think of age two as the age of power struggles and three as the time when the conscience comes on line with it’s powerful ability to generate shame. Basic trust may already have been solidly internalized so that trauma is now manifested differently. Many caregivers, even those with significant impairment, may have been able to nurture during the earliest years but hit their limits later. New issues such as power struggles and rivalries may not be handled well and personality mismatches can appear. Also, losses, abuse, violence, and other traumas can follow relatively intact earlier years. When trauma and deprivation happen at this slightly later period I see the “inner child” metaphor as a more true way to capture the intense purposefulness with which the client may seek connectedness.

When damage is built on a relatively more intact foundation, I think some additional emotions come into the picture. Anger at the caregiver’s failure is more of a factor. That entails more issues. There may be fear of expressing anger, which can result in self-directed aggression or identification with the aggressor, such that an attitude of self-criticism is adopted. Alternative soothing and sensations may be discovered as substitutes for love,  becoming compulsions later.

Perhaps most significantly, with greater cognitive development, the child may become sensitized to the threat of hopelessness or helplessness. As children in troubled circumstances become aware or believe that they bear sole responsibility for their own and siblings survival, they also react to the possibility of not having the resources to succeed. Even unconsciously, this equates to loss of hope and may be warded off at great cost. What if my primary caregiver is not capable? Fear of the experience of hopelessness can be held off by denial or bravado. “I can handle anything.” When such denials last into adulthood they can contaminate conscious thinking and become a block to adult acceptance. Acceptance of what can’t be fixed (and is therefore hopeless), is painful beyond present reality. This is one reason why clients who have experienced childhood deprivation and abuse may have great trouble accepting that they have survived childhood and that they now have the necessary equipment to navigate their world. To them, it feels like childhood must be repeated and repaired rather than left behind. 

Lack of internalized connection vs. not accepting what wasn’t?

At this point, it may be hard to tell whether the need to be convinced of the therapist’s caring comes from missing internalizations in the earliest years or the intolerability of facing and accepting a past associated with fear of ultimate hopelessness. To me, experiences like the reader’s of not existing in the therapist’s mind are among likely indicators of early internalizations that never happened or that were not very solid and have been disrupted under stress. At the very least, it is worth asking how much we are dealing with failure to internalize love vs. seeking to undo early pain and the dread of hopelessness.

What conditions promote internalization and healing?

Genuine caring on the part of the therapist seems to be a necessary but perhaps not sufficient requirement for trust to be built. Without trust, it is hard to expect the client to embark on the emotional risk taking involved in accepting connection and internalizing it. Furthermore, without a genuine connection, there is nothing to internalize. The conditions for acceptance are not very different. Acceptance also involves a significant emotional risk. Emerging from denial of the experience of hopelessness is no less frightening than a child with limited understanding having to face death or annihilation. The client must be ready to face hopelessness and loss of what was experienced as necessary for life, even when those fears have been held out of consciousness. There needs to be a place safe enough and emotionally supportive enough to undertake the painful process of accepting aspects of primal love that can not be replaced and losses that must be written off.

Perhaps a way to summarize is that, in my current view, holding back on genuine connection and caring does little to help, and tends to limit progress in the areas discussed, involving early developmental problems. Moreover, as the reader says, “how flexible and creative she’s been in doing this.” There are many ways that real feeling and connection can be communicated without losing sight of potential harm.

Jeffery Smith MD

Photo by Lucas Sankey on Unsplash.

____________________________________________

As always, I would invite comments, and also, if you find these posts interesting, please tell your friends and colleagues.

PS: If you are considering further training beyond single therapies or limited problem areas, enrollment is open now. Click below to learn more.

16 Comments

  • This makes so much sense. One of my patients (clients?) sent this to me and it fits the relationship we have developed over years of therapy. You mentioned getting flak for using “patient” instead of “client.” In my view, client sounds too businesslike and being a patient involves a sense of taking care of someone else. I also understand why some people dislike the term patient because it doesn’t necessarily convey the feeling of being partners in the quest for healthier functioning. Thanks again for posting this.

  • Really enjoyed this post! I feel it helps to convey more of what I feel like is going in my therapy and I’m sure many others in and seems more understanding of the struggles and blocks that seem to come up against. At times some posts I read (and I know this is simplified) but can feel a bit more like they are saying ‘your therapist can never give you the love you want and you just need to grieve that’ and it is incredibly frustrating.

    Lot of my stuff is preverbal and although I ‘know’ my therapist care’s is is somewhat impossible to internalize or integrate that care. The trust sometimes starts to build but it feels quite fragile and unstable like a house of cards one minor slip up or mistaken comment cause it to come tumbling down. No amount of ‘self talk; reframing etc seems to help this. I love however when you say that “Often, the things that finally convey trustworthiness are the slips and uncontrolled moments that reveal a therapist’s genuine humanness” My therapist is very relational with strong boundaries which can at times feel like she is withholding herself (perhaps not even always knowingly). It is in the moments that she is not and has accidentally shared something small (like get annoyed by something someone said to me) or perhaps said something she might not have said when her therapist hat was more firmly in place that that trust seems to build and stick. I am able to integrate it more and it is where most healing has happened for me. Innocuous moments that show her genuineness and care. For me, being more explicit but not forced or contrived with the care also helps. She said something seemingly relatively innocuous the other day highlighting her care and I literally felt the calmness flow through my body. I didn’t even realize until that moment how much on alert I had been throughout the session. It was so so minor yet so so big.

    In regards to the ‘client’ versus ‘patient’ comment. I have gotten very annoyed by my therapist calling me a patient and have told her so. I much rather client as I feel we are more on an equal footing (we are not I know) but at least it feels more working together in a process to achieve some positive outcome. ‘Patient’ feels very top down and because of the way the traditional medical model is set up more like you are the all knowing power and there is something wrong with me which you are there to fix. I am less a part of the process. Anyway I have rambled on now so I will stop. Thanks again for the post!

    • I totally agree with your frustration about the idea that ‘your therapist can never give you the love you want and you just need to grieve that’. I tried to grieve for years and it never worked. And I was made to feel, often unintentionally, like I was the problem. But now I am realizing that my previous therapists were unable to give me the love I needed because of their own flaws, fears, and limitations, not because it’s some universal truth. I also think that love is really essential for healing complex trauma; it’s not possible to grieve away the need for something essential. Telling someone to grieve a lack of love seems similar to telling them they should simply grieve not having enough oxygen or water. I wish you healing and hope you find the help you deserve.

  • Thank you for this article. I can definitely relate to having difficulty “feeling that one still exists even when the therapist is not physically present”, but for me this feeling that one doesn’t exist persists even in the presence of the therapist. I’ve been in twice weekly therapy for three years yet every time I enter the session I feel like I do not know who this person across from me is. I feel intense fear that they are not the same person, or like a body double has replaced them. Not knowing who they are, I also get no clues about who I am either, or how I’m supposed to be. I am lucky after many years to finally have a skilled a competent therapist, and my insight and self awareness has grown tremendously, but the way I feel is very slow to change.

    • I hope you and your therapist are working on understanding why you have trouble seeing your therapist as the same person each time. That symptom is not unique, but may have a specific origin related to your history. JS

    • Hi JNB, This is something I also struggle with somewhat. I find myself on edge at the start of each session as if it is a new person. I mean logically I ‘know’ it is not and I have spent many years in therapy with her and remember past sessions but this is not about logic, it’s about feeling. The longer it is between sessions (even if it’s just a day longer) the worse it seems to be. I sometimes joke that even after 6 years some sessions feels like the first session with her. I have similar feelings with family members if I do not see or speak with them for a while. In therapy this feeling does start to dissipate a bit once we start talking more especially if she is more conversational in nature at the beginning. On the days she waits for me to lead or does not say much at the start the feeling stays around a lot longer. I put mine down to the inability to ‘hold onto her’ or the connection to her when she is not there. Again, logically I can think about her and ‘know’ she is there somewhere but I cannot hold onto and integrate the ‘feeling’. No amount of trying to ‘think’ something into existence seems to help change that feeling. I think it is very hard for someone who has not experienced this to really understand what is meant by that. She suggested CBT reframing once which highlighted how difficult it is to convey to someone. Despite my reluctance I did try it but in my opinion this is not the answer to this. I am not really sure my therapist really understands although she does try.

  • Hi again. I am the blog reader quoted in the first two blurbs in the post. I appreciate, Jeffery, that you engaged with my comments thoughtfully. Based on my experiences as a client, I think you are right that self-awareness of the part of the therapist is key. One thing all my bad therapists had in common was poor or underdeveloped self-awareness. I also agree that explicit expressions of the therapist’s feelings (especially love) can be helpful to some clients. One thing I want to challenge you about is your idea that empathy is the core of primal love and it is ultimately what helps the client heal. As I noted in my earlier comments, I have had therapists who were quite empathetic, yet they were unable or unwilling to meet my needs, especially the needs of my young parts. My current therapist is also empathetic, but what she offers me is more than empathy (i.e. more than just a sense that she understands me or feels with me). The fact that she actively figures out how to meet my needs in ways unique to me and our relationship is really what makes the difference; I guess the distinction is in taking action vs. just understanding, perhaps. She doesn’t just understand my pain; she actively tries to make things better. And lots of times she can actually do so! Lots of therapists seem to really fear trying to meet clients’ needs; they don’t want to get over-involved or cross boundaries. And of course, it is quite possible for a therapist to cross boundaries in exploitative and harmful ways. But in my experience, a refusal or inability to meet a client’s needs can be just as harmful and can replicate childhood trauma. I’m not saying here that empathy isn’t important; I’m just saying it’s not always enough.

    • Hmm, I have to agree that doing one’s best to meet the client’s needs is part of what I was trying (unsuccessfully) to cover with the word empathy. Thanks for the correction. JS

  • Yes I also wondered about the use of the word empathy and do feel there is more needed so thanks for the clarification Jeffery.

    It’s nice to see pet lover that your therapist meeting some of your needs has helped. Do you have any examples you would be willing to share?

    I have watched many trainings on trauma which has often outlined the ‘danger’ to therapists of meeting a clients needs and how if they do the client will always want more and more until the therapist can’t sustain it and either burns out or crosses some terrible imaginary boundary line they can’t come back from. Whilst I’m sure this can be the case for some clients I don’t feel it is the case for all and I find it incredibly frustrating when I read so many therapists will not meet any needs outside the one hour session especially for clients with complex trauma.

    At one point in my therapy I was fortunate that I able to see my T twice a week. It felt very regulating snd many times I didn’t even feel a need or want for the 2nd session. Due to circumstances that is no longer the case which is fine but I still think some quick touch point (eg one short response to an email or text – not therapy) between sessions would be helpful. She seems reluctant and does not think it would help in the long run which is becoming an issue for me. I truly believe that it or something similar would help me to maintain connection, hold her in mind and integrate the belief that she also holds me in mind. No amount of words ‘I do hold you in mind’ seem to fulfil that. If the worse case scenario were to arise (I.e it caused me to want more and more or for her to start to feel resentful or burn out I would like to think we would both (particularly her) be on watch for that and be able to draw a line in the sand). I do try to stand back and ask myself if this is what Jeffery describes as just an unwillingness to give up ‘hoping’ and ‘trying’ or simply more of a inner ‘knowing’ of what would be helpful for me

  • Susan, I can’t say for sure what would help you, but I went through what you’re describing with some of my previous therapists and I have read/seen the same trauma training you are describing. And now I think the idea that meeting a need will make it worse is actually backwards! At least when it comes to essential unmet needs from childhood. I can give some examples. A lot of the things I’ve found most helpful are ones that some therapists insist are harmful. Touch is an important part of my therapy, including extended periods where she holds me. My therapist is very available outside of sessions for check-ins or if I am distressed. If she will be unavailable, we plan for that well ahead of time. She explicitly interacts with my young parts, including through activities like reading to me. She tells me she loves me. There’s also other things she does that are very specific to me and would take some time to explain. But the point is, she doesn’t assume that my young parts are needy monsters that will swallow her up if she lets them get close. And that in itself has been really healing. Actually, I can give a recent example of how meeting a specific need decreased the need. For a while, the only time of day I could not contact my therapist was when she was asleep. She is a deep sleeper and worried that I would call and she would not hear the ringtone and that would distress me more. The problem is, I have a lot of childhood trauma related to nighttime events (including abandonment) so often that is when my child parts would be really activated at night. We tried different things like her making me a recording of her singing, giving me different objects like a blanket, etc. These things worked a bit but wasn’t enough. Eventually, she set an extra loud ringtone and said I could try calling at night. Since that happened about 6 weeks ago, I have called her at night exactly once. She did wake up and we talked for a few minutes. Other than that, I have not needed or wanted to call her late at night. But knowing that she will pick up if I call is extremely comforting for my young parts, and that is enough to settle them. Overall, my level of need for her presence and attention varies over time depending on what’s going on for me. But I feel much LESS desperation and longing than with previous therapists who were more withholding. I have wondered how she is able to be so available to me without burning, and she says it’s because she organizes the rest of her life with the knowledge that she is a complex trauma therapist and works with people who need a high level of attention to heal. I think some therapists try to work with trauma clients but don’t realize quite what they are getting into.

  • With regard to me feeling(and being disturbed) that the therapist only thinks about me in my presence in the therapy session – I would like to add something further…….

    We are not the same person rationally as we are emotionally.
    My therapist encouraged me with my writing, and so, at a rational intention, I got into the habit of -at the end of a session – handing her something I’d written to read later. My rational reason being that , as I had benefitted by her encouragement to write, I was showing my gratitude.

    But, there is an underlying emotional reason. It’s my way of attempting to get her to think about me outside the therapy session.
    This is what I don’t understand……
    I think about her outside the therapy session sometimes, so why shouldn’t she think about me sometimes when I’m not in her presence? Rational me thinks she may do occasionally, but feeling me is convinced that if I didn’t give her something to read I would have died to her until she looked in the appointment book just before the session.

  • Jeffrey,

    I have read your recent article and have always looked forward to your writings. I have learned from them and shared them with my former therapist, who was jealous of you, but knew you were too far away for me to work with, so he “won”.
    I desperately struggled with attachment to him and he fueled it by creating a drastically unhealthy trauma bond and severe dependency upon him. He knew my deprivations and exploited them. This lasted for ten years. I paid for this dearly by the psychological, emotional, financial and spiritual rape he called “the process”. I supplied the adoration he thrived on and the cash he loved. The zillion red flags waiving in my face and sometimes smacking me were confused with the “butterflies” I experienced pre/post sessions, which is common for a person to confuse who had experienced developmental traumas. If I had only listened to my instincts and body; I did not trust myself and he ran with that.
    I experienced re-abandonment trauma every session. I have thousands of email and phone calls from him perpetuating neediness. He knew exactly what he was doing, and when I was waking up from this ‘hypotonic’ state…. when he knew I knew his game, he pulled every manipulation to get me to not leave. It took me months to finally get away as he berated me, lying and smearing me to anyone he could; yelling at me, insulting me, hanging up on me and once he actually gave me the ‘finger’.

    He would often talk about other clients in detail, which I thought was horrifying.
    When he pressed me to work through a past trauma that was already worked out, I shared with him details and he burst out laughing at me and my blood ran cold because is was the worst thing a person could endure. but I remained seated, despite every cell in my body telling me to get out of his office and never return. I went through living hell for months as he encouraged me to stay with it, knowing he was cashing in heavily at my every expense. I stayed seated that session and apologized to him for laughing at me…..insanity.

    He actually told me he would have his license revoked if they knew how he did therapy with me. I was “special” as he often reminded me. He had no boundaries and thought he was excellent at his job, reminding me how in demand he was and turns people away and how much he gives to me and that I should be more appreciative; unbelievable to write this out.
    The times I called him out on certain concerns, he turned on me, blaming me for it all, attacking me, at times, viscously. I concluded he was a narcissistic psychopath. Talk about 20/20 hindsight!
    It’s been a year and a half and this is still effecting me since I want revenge; albeit, dumping him was revenge. Giving up my wish and fantasy is the very hard part to release. I know he is evil and this was not my fault but get angry with myself for ignoring my gut; which I will never do again. My spouse saw through him as did my children, but my denial was deep.
    He spun me into a whirlwind of confusion, despair and deception all the while telling me it was normal to feel these things. I could go on for sometime but will end this comment. Thank you for your work and for the chance to share this with this community.

  • I had a doctor, once, who fulfilled some of my childish needs in ways that were specific to me (for example, writing me letters and sending them through the US postal service) in what seemed like an attempt to encourage dependency and the hope that she could assuage my longing for a mother.

    Over time, my attachment to her deepened, intensifying to the point that I mostly thought about what I wanted her to do for me (holding me was one thing I fantasized about and thought was essential to get from her, and the therapist I was also seeing at the time. Neither one of them would hold me, as Petlover’s therapist does, but I certainly longed for it.)

    Eventually, as I became more dependent, my behavior began to deteriorate. I began calling the doctor at night, neglecting my family, and thinking only of how I could get my unmet childhood needs for love and affection fulfilled any way I could. I had fantasies I tried to enact, and did things such as refuse to leave the doctor’s or therapist’s office, and going to the office outside of appointment hours.

    Eventually, my behavior became too much for the doctor. She discharged me, citing that she was “not the right doctor” for me. It was devastating, to lose an attachment I had placed such energy and hope in. The hope was that the pain of my childhood would be erased and my emotional and physical needs would be fulfilled by the doctor.

    I cried everyday for at least 6 months after she abruptly discharged me (I could have seen it coming, because I KNEW that I was giving her power, that I was abdicating myself, yet I did not KNOW how to do it differently, or I hadn’t the energy).

    I want to say that, never having received the kind of nurturing that Petlover describes with her therapist, I have had to learn other ways to cope with the pain of my childhood. The pain has largely ruled my life and for most of my adult life, was a driving force in almost every decision I made.

    This is what I have learned:

    1. I still take medication, even though I would much rather have a way to manage intense feelings another way. I am still working on this!

    2. I love grounding exercises and “mindfulness”. Jeffrey has written about mindfulness elsewhere on this blog. Grounding is essentially mindfulness.

    3. This is how I ground: I have learned that when I start to fantasize about the doctor or therapist holding me or otherwise soothing me, I can short-circuit this, ultimately dissatisfying, response to my pain by focusing on the physical. I have trained myself to immediately focus on the feeling of myself on the chair I’m sitting on, or the feeling of the bed I am lying in, or my feet on the ground.

    4. When I’m not in an intense abandonment place, I PRACTICE GROUNDING. It feels good and is calming, and is then more accessible when I start to be paralyzed and chaotic by an abandoment/longing for nurturing feeling/mental sensation/fantasy. It’s not as exciting as the fantasy. But it is ultimately a way out of a distress that seems so intolerable, the only reason I am tolerating it, is that I am not dead. It was, “virtually intolerable”.

  • Sylvia Beth,
    I hear you! Every day I thank the therapist I had in my late twenties for not responding to my intense erotic transference feelings. With hindsight, I can now see it would have crippled my emotional development……..
    At the time I was infatuated with him. He explained to me, “That at the very least it shows you have a need for a man in your life”.
    But, here’s the thing. The attachment was so intense I could not break it. At the same time, I realized that, whilst I had this attachment to him, no other man stood a chance.

    What to do? I did the only thing I could do – I acted out in a very negative manner – knowing that, ultimately, he would end our therapy.
    Many years later, I’m so glad (although painful at the time) he did end the therapy. It was then that I met the man who became my husband.

    Therapists – like all of us – have egos. But, they cannot be the solution to our problems, and , in my opinion, it’s best if ultimately they (and us) understand this.

Leave a Comment